Safety of percutaneous nephrolithotomy in patients on chronic anticoagulant or antiplatelet therapy.

In developed countries, the incidence of cardiovascular disease is increasing, therefore, anticoagulant and antiplatelet drugs are a widespread treatment nowadays. Percutaneous nephrolithotomy (PNL) is the first-line treatment for large or complex stones (> 2 cm) and remains an alternative for the smaller ones. The objective of this study is to analyze whether PNL surgery is a safe procedure in patients under a treatment discontinuation protocol for anticoagulant or antiplatelet therapies. We retrospectively studied 301 patients who underwent PNL in our hospital between 2008 and 2016 and identified 46 patients on chronic antiplatelet or anticoagulation treatment. With respect to PNL outcomes, the stone-free rate was similar (78 vs 74%, p = 0.762) in both groups, without any significant differences in the overall postoperative complications (17 vs 26%, p = 0.203). The incidence of hemorrhagic complications was similar between groups (12 vs 9%, p = 0.492), as demonstrated by the mean drop in hemoglobin (Hb), which was comparable in both cohorts (2.2 ± 1.3 vs 2.0 ± 1.4 p = 0.270) and the blood transfusion rate (14% in group A and 8% in group B, p = 0.205). No thromboembolic events were found within the year after the PNL procedure. PNL is a safe and effective intervention in patients under a treatment discontinuation protocol for anticoagulant or antiplatelet therapies. Although our study demonstrates the feasibility of this protocol, new scientific evidence aims to stratify the thromboembolic and bleeding risk of each patient to individualize the perioperative management thereafter.

Nefrolitotomía micropercutánea: una nueva opción terapéutica para la litiasis renal pediátrica / Micropercutaneous nephrolithotomy. A new therapeutic option for pediatric renal lithiasis

Introducción: La nefrolitotomía micropercutánea es una evolución de la cirugía percutánea convencional en la que se accede al sistema pielocalicial mediante orificios de mínimo calibre. Su objetivo es la completa eliminación del cálculo, disminuyendo la morbilidad producida por la realización de trayectos percutáneos de mayor diámetro. Material y métodos: Presentamos la realización de una nefrolitotomía micropercutánea en una paciente de 14 años con litiasis renal de 35 mm de diámetro situada en la pelvis renal. La cirugía se realiza en posición supina de Valdivia modificada en Galdakao. Punción guiada por ultrasonidos y fluoroscopia. Se emplea la aguja 4,85 Charrière (Ch) del set de Microperc®, completando el procedimiento a través de la vaina 8 Ch. Lasertricia con láser Ho:YAG. Se deja catéter doble J al finalizar el procedimiento. Resultados: Tiempo quirúrgico de 170 min. Estancia hospitalaria de un día. Cólico renal a las 72 h resuelto con analgesia en domicilio (Clavien I). Reincorporación a la vida escolar al 5.° día. Retirada del catéter doble J a las 2 semanas. La paciente está asintomática al mes de la intervención, observándose en la ecografía abdominal un resto de 4 mm en el cáliz inferior. Conclusión: La nefrolitotomía micropercutánea es un nuevo paso adelante hacia la búsqueda de la menor invasividad en el tratamiento de la litiasis renal, siendo una técnica segura y efectiva en la población pediátrica, pudiendo ser realizada en decúbito supino en riñones ortotópicos. Futuros estudios y trabajos colaborativos ayudarán definir mejor sus indicaciones, a optimizar su técnica quirúrgica y a analizar su coste-efectividad comparada con otros tratamientos

Introduction: Micropercutaneous nephrolithotomy is an evolution from the conventional percutaneous surgery in which pyelocaliceal access is obtained through minimum bore holes. Its objective is the complete removal of the calculi, lowering the morbidity associated with larger bore percutaneous tracts. Materials and methods: We present the case of a micropercutaneous nephrolithotomy performed in a 14-year-old female patient with a 35 mm diameter kidney stone located in the renal pelvis. Surgery was performed in the Galdakao-modified supine Valdivia position. Puncture was done under ultrasound and fluoroscopic guidance. The 4.85 Ch needle of the Microperc® set was used, completing the procedure through the 8 Ch working shaft. Lasertripsy was done with the Ho:YAG laser. An indwelling double J stent was placed at the end of the procedure. Results: Operating time was 170 min. Hospital stay was one day. She suffered renal colic after 72 h, which was resolved with oral analgesic treatment at home (Clavien I). She returned to school on the fifth postoperative day. The double J was removed at two weeks. At one month of the surgery, the patient is asymptomatic, a 4 mm lower calyx residual stone being observed in the abdominal ultrasound. Conclusion: Micropercutaneous nephrolithotomy is a step forward toward the search for a less invasive kidney stone treatment. It is a safe and effective technique in the pediatric population, and it can be performed in the supine position, even in orthotropic kidneys. Future studies and collaborative works will help to better define its indications, to optimize its technique and to analyze its cost-effectiveness compared with other treatment options

Micropercutaneous nephrolithotomy. A new therapeutic option for pediatric renal lithiasis.

INTRODUCTION: Micropercutaneous nephrolithotomy is an evolution from the conventional percutaneous surgery in which pyelocaliceal access is obtained through minimum bore holes. Its objective is the complete removal of the calculi, lowering the morbidity associated with larger bore percutaneous tracts. MATERIAL AND METHODS: We present the case of a micropercutaneous nephrolithotomy performed in a 14-year-old female patient with a 35 mm diameter kidney stone located in the renal pelvis. Surgery was performed in the Galdakao-modified supine Valdivia position. Puncture was done under ultrasound and fluoroscopic guidance. The 4.85 Ch needle of the Microperc(®) set was used, completing the procedure through the 8 Ch working shaft. Lasertripsy was done with the Ho:YAG laser. An indwelling double J stent was placed at the end of the procedure. RESULTS: Operating time was 170 minutes. Hospital stay was one day. She suffered renal colic after 72 hours, which was resolved with oral analgesic treatment at home (Clavien I). She returned to school on the fifth postoperative day. The double J was removed at 2 weeks. At one month of the surgery, the patient is asymptomatic, a 4mm lower calyx residual stone being observed in the abdominal ultrasound. CONCLUSION: Micropercutaneous nephrolithotomy is a step forward towards the search for a less invasive kidney stone treatment. It is a safe and effective technique in the pediatric population, and it can be performed in the supine position, even in orthotropic kidneys. Future studies and collaborative works will help to better define its indications, to optimize its technique and to analyze its cost-effectiveness compared with other treatment options.

[Retroperitoneal benign fibrous histiocytoma. Presentation of a case]. / Histiocitoma fibroso benigno retroperitoneal. Presentación de un caso.

Presentation of one case of an extraperitoneally located Benign Fibrous Histiocytoma in a 59-year old male. Retroperitoneal tumours are extremely rare neoplasias, malignant in about 85% cases 35% of which are sarcomas. The benign fibrous histiocytoma is most often located in subcutaneous tissues, a deeper location being exceptional. They are usually clinically silent entities until size causes a shift or compression of other organs which cause the clinical signs and symptoms. In many cases, the neoplasia is detected by ultrasound. Computerized Axial Tomography is the technique that provides more data for the establishment of diagnosis, although for many authors Nuclear Magnetic Resonance can be more defining. The primary therapy is surgical removal, but relapses can occur if full exeresis is not achieved.

[Vascular prosthesis in kidney transplantation]. / Prótesis vasculares en el transplante renal.

OBJECTIVE: Three cases of kidney transplantation that required a vascular prosthesis are described and the literature reviewed. METHODS: Of 920 cases of kidney transplantation, 3 required a vascular prosthesis to repair the aortoiliac vessels. One patient with severe atherosclerotic disease had an aorto-bifemoral prosthesis (Gore-Tex) six months before renal transplantation and the other two patients required a vascular prosthesis to repair iliac artery lesions discovered during transplantation. RESULTS: The initial surgical results were satisfactory. No complications arising from the vascular prosthesis were observed. Two patients have a functioning renal graft, but the third patient developed acute tubular necrosis and tubulo-interstitial rejection and died from acute pulmonary edema. CONCLUSION: The importance of the preoperative cardiovascular evaluation in patients undergoing kidney transplantation is underscored. Some patients may require a vascular prosthesis. We should therefore be familiar with the prosthetic materials and the surgical techniques, which are not particularly difficult, and optimum results can be achieved. In patients with both end-stage renal disease and severe aortoiliac atherosclerotic disease, the controversy remains whether aortoiliac repair and kidney transplantation should be done simultaneously or in two stages.

[Skin metastasis from transitional cell carcinoma of the bladder]. / Metástasis cutánea de carcinoma de células transicionales de la vejiga.

OBJECTIVES: An additional case of cutaneous metastasis arising from transitional cell carcinoma of the bladder is described. Its form of presentation, dissemination pattern, pathological features, clinical course and treatment are briefly discussed. METHODS: This article reports on a 62-year-old male with bladder carcinoma stage PT3B, PN0, PMx, who underwent radical cystoprostatectomy and detubularized ileal neobladder four months earlier. RESULTS: A solid tumor with an ulcerated surface was found on the dorsal side of the left shoulder. Microscopic analysis disclosed neoplastic cells resembling transitional cells in dermis, the first manifestation of distant tumoral spread. Patient survival was only two months. CONCLUSIONS: Transitional cell carcinoma of bladder metastasizing to the skin is an uncommon finding despite the high incidence of this tumor, although more cases are being reported. Skin metastasis generally presents in the late stages of this disease and indicates a poor outcome.

[Sarcoidosis and urolithiasis]. / Sarcoidosis y litiasis urinaria.

OBJECTIVES: A retrospective study of patients with sarcoidosis and urinary lithiasis or lithogenic risk factors (hypercalcemia and hypercalciuria) was conducted to determine the degree of relationship of this disease with urinary lithogenesis. METHODS: From 1978 to 1993, 96 patients with sarcoidosis (68 females and 28 males), aged 17 to 77 years (mean 43 yrs), were evaluated. Serum and 24-hour urinary calcium were determined by the cresolphthalein complexone procedure. The presence of urinary lithiasis was determined from patient clinical data and/or the findings of the imaging techniques that had been utilized to evaluate these patients. RESULTS: 6.3% were hypercalcemic, 26.6% were hypercalciuric, 6.2% had a previous history of urolithiasis and 8.3% had a urinary calculus at the initial consultation. CONCLUSIONS: Hypercalciuria was present in about 25% of the patients with sarcoidosis, whereas approximately 15% had clinically documented urinary lithiasis.

[Echo-guided punction with pistol for extraction of retained urethral balloon catheters]. / Punción ecodirigida con pistola para extracción de sondas uretrales de balón retenidas.

OBJECTIVES: We report our experience with a percutaneous technique for the removal of a balloon catheter retained within the bladder, using transrectal ultrasound and the biopsy gun. METHODS: Using ultrasound equipment with a transrectal probe of 5 mHz, we introduce the biopsy gun with an 18G needle guided by the probe. It is aimed at the retained balloon, which is deflated by punction. RESULTS: We carried out this technique successfully and without complications on three patients. CONCLUSIONS: We believe this technique is simple, efficient and quickly resolves the problem with minimum or no morbidity.

[Kidney transplants from asystolic donors]. / Trasplante de riñón procedente de donantes en asistolia.

Review of our experience on renal transplantation with graft from removal in asystole. We have performed 31 transplantations of kidneys removed while in asystole, 25 of which were treated only with cardiocompression and assisted ventilation as support measures, the average asystole time being 45 minutes. Two donors were treated by in situ cold perfusion of the abdominal organs (time of asystole, 70 and 218 minutes). One patient was maintained with body cooling by cardiopulmonary by-pass for 90 minutes. Graft survival at three months was 77%, with a delay in the initial function of 70%, secondary to acute tubular necrosis, this being the only parameter in which a significant difference is observed when comparing them to those from a control group of 50 transplant performed over the same interval. No significant differences were seen at one year with regard to either graft survival or the recipients in both groups.

[Bladder metastases of pulmonary carcinoma. A report of 2 cases]. / Metástasis vesicales de carcinoma pulmonar. Presentación de dos casos.

Metastatic vesical tumours caused by blood- or lymph-borne neoplasias from any part of the body are extremely uncommon (less than 1% of vesical tumours), and even within this group lung tumours are the origin in a very small number of cases. Diagnosis usually happens in advanced stages due to the limited symptomatology exhibited. This paper refers two cases of vesical metastatic neoplasias from lung tumours, one an oat-cell anaplastic carcinoma and one epidermoid. Also, in the first one there was the peculiarity of haematuria being the early manifestation which lead to the diagnosis of lung neoplasia.

[Primary renal lymphoma in an HIV-positive patient]. / Linfoma renal primario en paciente V.I.H. positivo.

We report on an HIV positive patient with bilateral primary renal non-Hodgkin lymphoma that remitted with chemotherapy. The clinical and radiological features, which are initially not distinct from those of other tumors in the same site, and the therapeutic possibilities are discussed.

[Spontaneous rupture of transplanted kidney. Experience with 500 transplants]. / Rotura renal espontánea de injerto. Experiencia en 500 trasplantes.

We reviewed a series of 500 transplants and found 21 (4.1%) cases of graft rupture. All the renal grafts had been harvested from cadavers. Hemodialysis was required in 18 (85%), acute rejection developed in 12 and acute tubular necrosis in 12 (3 were related to percutaneous maneuvers for biopsy or PCN). All cases developed acute pain and oligoanuria. No significant difference was observed relative to ischemia time or HLA typing. Concerning immunosuppression and graft rupture, a significant difference was observed for the group that received low dose CsA combined with triple therapy (3 rupture grafts, 14.2%) versus the high dose CsA and steroid treated group (11 ruptured grafts, 52.3%), p < 0.01. Twenty grafts had ruptured within the first 15 days following transplantation and one at 8 months. Graft removal was warranted in 8 (38%) and conservative surgery in 12 (57%). Two grafts (16%) were lost and 1 patient (4.7%) died without undergoing surgery. Graft rupture is a severe complication that warrants immediate surgical management. Conservative surgery is a valid alternative in those cases with a viable graft.

[Tubercular ureteral stenosis. Endourologic treatment of 4 cases]. / Estenosis ureteral tuberculosa. Tratamiento endourológico de 4 casos.

Tuberculosis stricture of the ureter is a process that may lead to loss of renal function if undiagnosed and untreated at the right time. Currently, tuberculostatic agents combined with steroids, and the possibility of recurring to endourological treatment, achieve a high success rate. Our experience with 4 cases is described. All cases were easily resolved with minimally invasive techniques and have remained stable at follow-up ranging from 2 1/2 to 6 years. In view of our good results, we advocate the use of this treatment modality.

[Paravesical tumor of adrenal gland residues]. / Tumor paravesical de restos adrenales.

Presentation of one case of ectopic suprarenal tissue residues' tumour found at paravesical level. The singularity of this diagnosis, unless hormonally active, or when very large in size, as well as its various locations is recalled. Ultrasound, CAT and hormone characterization are the mainstays to achieve clinical diagnosis. Surgery is always the course adopted. Only when such an option is unsuitable, drugs are used to block the steroidogenesis.

[Renal transplantectomy]. / Trasplantectomia renal.

During the first ten years (1981-1990) of our organ transplantation program a total of 395 Renal Transplants (RTx) have been carried out in our Unit, 90 of which in 88 patients had to be subsequently transplantectomized. In 32 of them the reason was acute rejection (35%) including 7 renal rhexis, and in 30 chronic rejection (33%) (1 rhexis). There were 22 (24%) (1 rhexis) vascular complications leading to such procedure. The technique was chosen mainly depending on the amount of time elapsed between transplantation and transplantectomy, performing 47 subcapsular and 43 extracapsular manoeuvres. The complications developed were 7 (7.7%), mostly haemorrhagic. Our attitude when faced with non-functioning grafts due to chronic rejection is the complete withdrawal of immunosuppression performing transplantectomy only in the event of arterial hypertension or in the presence of symptoms of acute rejection overimposition.

[Long-term results of conservative treatment of ureteral fistulas]. / Resultados a largo plazo del tratamiento conservador de las fístulas ureterales.

Techniques for conservative management of different upper urinary tract pathologies have been widely used in the last decade. Endourological treatment of ureteral fistulas is one of the fields which has developed significantly. Our experience in the management of this condition consists of 9 patients that had been treated from 1983 to the present time. Four of these were in transplanted kidneys. Fistula repair was achieved in 8 cases, although one developed secondary urethral stricture. One patient required open surgical correction. There were no deaths or loss of any renal unit. A mean follow-up of 44 months revealed no complications. We consider this therapeutic modality to be the procedure of choice in patients with ureteral fistulas.